How Covid-19 is refocusing the discussion around drugs
The debate between prevention or punishment is receiving some ‘new thinking’ that may end up changing the way illegal substances are bought and used, says
John is a long-term drug user whose life is now stable on prescribed methadone. In late March when the Covid-19 pandemic hit, he remembers standing in a long queue outside the pharmacy waiting to get his prescription. “The pharmacist is also a post office. In other parts of town, they are within convenience stores or with Boots, the pharmacy is part of a big shop. We were stuck in the queue. I rang the pharmacist to tell him I was outside and he brought my prescription out to me.”
Neither pharmacists nor policymakers wanted unnecessary queues of drug users at chemists during lockdown. So in Birmingham, rather than methadone users having to go to the pharmacist every day for their prescription drugs, they were given a two-week prescription which they would have to measure out
themselves over the fortnight. Could the drug users cope? Would they use it all up in the first few days? “For most users it made a big difference,” says John.
Jamie, who runs a charity set up by former drug users like himself to provide advocacy services, agrees. “I was very supportive. We delivered safe storage boxes to store the methadone to those living in families. Of course, there were problems with some chaotic users, who needed more oversight but for more than 90 per cent it was a positive move. It should continue as the norm.”
Importantly, there has been no rise in drug-related deaths showing up in the coroner’s report during the first few months of lockdown and with the relaxation of restrictions there has been no rush from pharmacists to revert to the old daily routines. Marion Gibbon, the city’s interim assistant director of public health, is very positive about the difference it has made. “The results are in and we’ll stick with that. It hasn’t led to the problems that we were warned about.”
How the country handles people who use drugs is a contentious political issue. Like most of the country, Birmingham has a growing problem with drug misuse. Currently, it is estimated that there are 11,000 opiate and/or crack users in the city of whom just under half – around 5,000 people – are engaged with drug treatment services. There were 252 deaths related to drug poisoning in the city between 2016 and 2018, the highest number since records began in 2001 and a rise of more than a fifth on the preceding three-year period. That puts the rate of deaths from drug use in Birmingham at 6.3 per 100,000, significantly higher than the overall rate for England of 4.5. At the same time, since 2015 there has been a 46 per cent cut in funding for drug and alcohol treatment services in the city, with the budget falling from £26m to £14m.
Over the past 40 years Judith Yates has seen every aspect of the urban drugs scene. Starting as a GP in an inner-city Birmingham practice in 1980, she saw the local and the global interconnect: the rise in mass unemployment and loss of hope in the Thatcher years combined with the surge in brown, smokable heroin flowing in from war-torn Afghanistan. “It was a deadly combination,” she says. The emergence of HIV in the late 1980s was another difficult period; community drugs teams were set up, followed by needle/syringe exchange programmes. She fondly recalls the extra money the Blair government allocated for drugs treatment with locally-based, well-funded Drug Action Teams before the impact of austerity, especially from 2013, led to a resurgence in both illegal drug use and drug-related deaths. “Since the cuts introduced by Andrew Lansley (then health minister) we’ve seen a halving of budgets and a doubling of drug-related deaths in the city,” she remarks acidly. Now involved with drug monitoring in the city in a voluntary capacity, she knows the devastation that drug use can bring to people’s lives, the adverse childhood experiences that users have often endured and the impact that disordered, dysfunctional life can have on their own children. Yates is clear on the policy approach that is needed. “Treating drugs as a health issue not a criminal justice issue is the key.”
For decades the UK has followed the lead of the United States in seeing drugs as primarily a criminal issue. The tabloid press and Conservative politicians have taken a hard line on drug misuse, supported the “war on drugs” and targeted “liberals” who have argued for the legal regulation of “soft” drugs and for the focus to be on prevention and harm reduction rather than punishment. All the indications from around the world are that this policy has dismally failed. In the UK, drug use, drug deaths and the associated social costs are all rising, along with the consumption of illegal drugs like cocaine for recreational purposes. There are now signs that the agencies which confront these issues daily recognise that it is time to change course.
That’s certainly the case in Birmingham and across the West Midlands. David Jamieson, West Midlands police and crime commissioner, is an astute Labour politician. The former MP for Plymouth Devonport knows that he needs to sidestep the “culture wars” booby traps. So he avoids gesture politics and grand statements. Instead, he tells me, “we’re following a pragmatic approach. We can’t wait for the government to change the law. We’re looking at what we can do now.” He emphasises the growing social harm of drug misuse; the criminal impact, which increasingly worries senior police officers as well as working-class communities threatened by criminal gangs; and the huge economic costs. In February 2018, following public consultation, Jamieson set out a new approach to drug policy. His report drew on Home Office figures which estimated that the annual cost of substance misuse to the West Midlands region was £1.4bn. This included the cost to society of drug-related crime, additional health service use, drug-related deaths and social care. In his West Midlands patch at least half of all theft, burglary and robbery is committed by people who use heroin, crack cocaine or powder cocaine regularly, while every three days in the West Midlands somebody dies of drug poisoning. Against this backdrop, the report called for new thinking and a mature discussion about what needed to be done, along with eight recommendations for action.
Some were small-scale measures such as the proposal to improve access to Naloxone and other interventions that reduce the lethal impact of drug overdoses. Naloxone comes as either a needle or a nasal spray. When it is squirted up a nose, users come round quickly. “We’ve now got 50 officers in Birmingham city centre trained in its use and carrying it around with them.”
Another proposal was to “look at the top guys running the drugs trade”. Jamieson has set up a new team of financial investigators able to look at unexplained property, wealth and cash. “It’s tricky; it takes a long time but over the summer we’ve seized £7m. We aim to plough that back into drug support services but first I have to get that money back from the Home Office. At the moment they claim most of it, even when we’ve done the work.” He’s in discussions with Kit Malthouse, the police minister, about regions being able to keep at least half of the proceeds that they seize from criminal gangs.
A further measure the Police and Crime Commission (PCC) is pursuing is the establishment of a heroin
assisted treatment (HAT) centre. This would “use a current medical facility and treat 10-15 heavy end users”. One of the local council officers involved in the discussions on operationalising the HAT admitted to me that setting it up is complex. “You have to find the right facility and be able to match it to the right cohort of users. It’s no good if they are miles apart.” But Jamieson is confident that “we’ll be able to land it by early next year”.
We’ve spent billions on this pandemic; we should be doing the same to tackle drug use
He happily acknowledges that they have been learning from Middlesbrough, where since autumn 2019 the PCC has been funding a small trial initiative offering heroin assisted treatment to current users. Entrenched heroin dependency is a key driver of crime in the area, with a cohort of “revolving door” offenders placing increased demand on the courts. The PCC realised that a different approach was needed and worked with partners to explore the use of new methods. Heroin assisted treatment is a medical approach for people with a long-term dependency on heroin, who have failed to respond to any other drug treatment. Launched in October 2019, it initially targeted 15 of the most “at risk” people in Middlesbrough, who were causing the most concern to police, health and social services. Run by a nurse and GP, users attend the specialist facility twice a day, seven days a week, where they are assessed and prescribed, and self-administer under the supervision of medically trained staff. Once their drug use has stabilised, participants spend time with specialists from other agencies to help them rebuild their lives and reintegrate into society. Results from the study have been very positive with users reporting a stabilisation of their lives, a break from using street heroin and an end to shoplifting, burglary and other crimes that financed their drug habit. In August an extension of the scheme for a second year was announced.
Another example comes from Glasgow where the city council, backed by the Scottish government, has long called for the establishment of supervised drug consumption facilities in the city. However, these are interpreted as contravening the Misuse of Drugs Act 1971 and have therefore been repeatedly blocked by the Home Office. Exasperated by the failure to address the issue, former drug user Peter Krykant recently took matters into his own hands and modified a van to enable people who use drugs to consume them safely and hygienically within it. He risks arrest by operating the van, which exists in a grey area of the law: as selling or assisting in the procurement or preparation of illegal drugs is an offence, users of the van bring their own substances and prepare them alone. His thinking is that by pushing the boundaries, an official facility where people can get proper help and support becomes inevitable. While his van ensures a clean environment safer than the street, an official facility could provide services such as wound care, signposting and treatment and thereby enable a more comprehensive preventative service.
One of Jamieson’s eight recommendations was to consider the benefits of supervised drug consumption rooms. This support is typically targeted at hard to reach homeless people, improving their access to treatment while taking their injecting and needle litter off the streets. Just before lockdown, the commissioner published his report “Out of Harm’s Way”, which assessed the evidence regarding drug consumption rooms and showed strong and supportive backing for their introduction as a way to reduce the harm caused, and the costs incurred, by drug use. Jamieson has been to visit such a facility in Geneva to see how it works and its benefits but he admits “it’s a tricky area. Progress has been slow so far and it’s mainly a health issue.” His budgets wouldn’t cover its introduction.
Illegal drug use also provides the setting in which hepatitis C thrives. More than half of all those suffering from this inflammation of the liver are drug users, who get the virus from sharing contaminated needles or other infected equipment. Currently there are around 143,000 people with hepatitis C in England, of whom around two-thirds are unaware that they have the infection. These are mainly within marginalised groups such as people using drugs and the homeless. NHS England has set the goal of eliminating hepatitis C from the UK by 2025 but most patients don’t go to hospital for treatment, both because they are unaware of the condition as they are asymptomatic and also due to their fragile life circumstances. The main voluntary organisation working on the issue, the Hepatitis C Trust, knows that tackling the issue successfully requires innovative solutions that don’t rely on traditional NHS appointment mechanisms and also draws on the experience of previous sufferers.
Philippe Bonnet works for the trust in Birmingham. As he puts it, “if we want to eliminate the virus we need to take the treatment to those most likely to have it”. Which is exactly what he does. Equipped with a portable machine and accompanied by a nurse, Bonnet pursues a Heineken strategy: he goes to the places that others don’t reach.
So he travels to the hotspots around the region – its homeless hostels and day shelters – with his mobile laboratory able to conduct up to four tests at a time. The machine costs £40,000 to £50,000; it’s heavy (15kg) but portable; and a simple finger-prick test offers the blood into a cartridge which is taken out of the machine and once dried gives the test result within an hour. He raises awareness among users and professionals about the issue and those testing positive are given an eight to 12-week medication course of anti-viral drugs. The users who test positive – between a third to a half of those tested – get their medical prescription from the nurse just a week later.
It’s not all plain sailing. Some people choose not to have the treatment. Bonnet acknowledges that “there’s low self-esteem among many”. However, overall, the outreach programme is working. This is the type of preventative approach to marginalised groups that Bonnet sees as getting results, rather than the punitive and penalising style that often characterises policy towards drug users.
It’s this broader thinking that shapes the new strategy for tackling drug and alcohol addiction that Birmingham Public Health produced just before lockdown. Its Triple Zero City strategy is ambitious, looking to cut deaths and overdoses to zero by 2030 and to ensure that all people using drugs receive appropriate support and treatment. Interim assistant director or public health Gibbon knows that these targets are aspirational. “Our ambition is to get as close to them as possible,” she says.
Working across agencies will be crucial. She and her colleague Chris Baggott are very aware of how hard the budget cuts have hit the service. Baggott says that “joining up with others can make our budgets more effective. Our partnership working has improved during Covid-19. We’re getting everyone together now. The ‘virtual round table’ has made things easier.” Gibbon is increasingly optimistic about the ways all the agencies, including the voluntary sector, are able to work together. “Previously, we were fragmented; now
it is much more cohesive.” Jamieson is on the same track. He describes himself as “a civic convenor, bringing all the agencies together”.
Yet the challenges are enormous – even more so when the recreational drug scene is considered. There’s a parallel drugs universe operating in the city with thousands engaging in illegal recreational drug use. Suzie is 30; a marketing executive rising on her career path. For her and her friends – some in professional jobs, others in hospitality or precarious, minimum wage jobs – picking up cocaine from a dealer after a few drinks in the pub is a normal part of her social life. There’s been some disruption during the pandemic but less now. “It’s a social drug, a pick-me-up to carry me through the night. Of my group of around 20 people – white, black, Asian, mixed race – 95 per cent are users. We have had no hassle from the police and no bad turns.” But she says that if it were legalised, “everything would be a lot easier; and if regulated a lot safer”. She draws a really clear line between her drug use and that of heavy end drug users like her dad, who is a heroin addict. Officially, the law draws no distinction but turning a blind eye to recreational drug use lessens the overall credibility of the system. Hard-line, anti-drugs policies sound increasingly hollow when leading politicians and cabinet ministers like Michael Gove admit to cocaine use.
With strapped budgets and ever-rising pressures, the agencies on the ground know that policies have to change and are increasingly prepared to look at the evidence from across Europe and listen to the experiences of former drug users. John’s life has stabilised on methadone and for more than a decade he’s been involved in advocacy and support for people who use drugs. He’s a firm advocate of heroin assisted treatment centres and has visited drug consumption rooms in several European cities and believes they should be introduced here. “We’ve spent billions on this pandemic; we should be doing the same to tackle drug use.” At the end of a long call he wryly remarks that “as a 63-year-old drug user I’ve managed to get by quite well in life”. He basically wants enough resources to be made available for others to be able to do the same. Jamie is similar. “We need a system oriented towards the human aspirations of drug users with a focus on harm reduction. We should recognise that everyone can change, even if not everyone will.”
Some of these harm reduction measures would be controversial with cultural conservatives. That’s why Jamieson treads warily, even though he has the backing of his senior police officers. But he feels that “we’re refocusing the debate. We are seeing quite a softening amongst opinion formers even in the media. A sea change is happening, even if it’s a bit glacial. I’m optimistic about our policies but I know there are no quick fixes.” He talks about the new HAT centre and I ask him if he shall invite home secretary Priti Patel to open it. He chuckles and replies: “She’d be most welcome. I’m here to move mountains, not to build divides. I’m about persuading people.” It looks like the invitation will be in the post.
Jon Bloomfield is an honorary research fellow at the University of Birmingham and the author of ‘Our City: Migrants and the Making of Modern Birmingham’